A Discussion with Ray Caggiano, Bob Blees, and John Barnshaw III, SIM

May 11, 2011

Background: This conversation between Ray Caggiano (SIM Special Projects Manager), Bob Blees (SIM Medical Advocate), John Barnshaw III (SIM Health Advocate), and Anny Gaul (Berkley Center) took place on May 11, 2011 in Charlotte, NC, at SIM’s U.S. headquarters. The interview was conducted as research for a series of issue surveys done by the Berkley Center with the support of the Luce/SFS Program on Religion and International Affairs. Anny Gaul sat down with the SIM staff members responsible for coordinating and supporting the organization’s medical projects to discuss what makes the healthcare provided by an organization like SIM unique, and how maternal health fits into the picture of their health care programs. The SIM team focuses on the holistic nature of their services, their roots in communities, and the importance of trust and empowerment. Sustainability is a central objective, and relationships trump statistics. But, they argue, the long-term impact is far greater.

Can you talk about SIM’s approach to international medical and relief work?

Caggiano: We are a Christian organization; the motivation for everything we do is to share the love of Christ with people. We work in places where others have not gone, so we often have people in the remotest and poorest parts of the world. We don’t go where there’s already a thriving hospital, for example. The motivation for doing medical work is from a holistic view: we want to share the love of Christ with people in body and soul, wherever people are hurting or starving or in need of help. We have many doctors and nurses and other medical professionals who feel called by God to go and reach out to the “least of these”. And so they go. Right now we have about 182 medical professionals deployed in 32 different countries. Some of them are in urban settings and some are very rural, but in almost every case we’re not running the hospital. Even if we started the hospital in the past, the idea is to have indigenous staff who can take over. We don’t want them to become dependent on us, but allow them to come to a place where they can do it themselves.

What makes the medical work and the healthcare services that SIM and similar organizations provide unique or distinctive from other providers (such as the public sector or NGOs)?

One of the things that I think is distinctive about an organization like SIM—but not exclusive to SIM—is that we have a desire and a drive to deal with what’s going on in an entire community, not just in terms of medical work. In terms of maternal health, for example, our people speak to the lives and the marriages and the interpersonal relationships of the people they are serving—to every aspect of their life. The approach tends to draw the men in as well as the women, because that’s an important part of the situation. Unhealthy practices in a family can lead to sickness and even death in some cases. So rather than just having a doctor doing surgeries, we deal with the whole community holistically, and address the broader issues that might be involved. In that regard we have a tendency to stay longer and to be engaged over the long haul, so people begin to trust the [SIM] people who are there. This way, you have a broader long-term impact and start to train local people. For example, we have an ex-pat nurse training local nurses who can go places where that ex-pat couldn’t necessarily go. And so we address the general health of the population that way. I think that is a distinctive value that a faith-based organization brings; other organizations tend to be a little more narrow or short-term in their view.

Blees: Or much more clinical rather than holistic—for example, we may work with a hospital, but the work that goes on with the families outside the hospital is what makes our interventions much more effective. Our AIDS project in Ethiopia started as home-based care for those that are dying of AIDS in the poorest areas of Addis Ababa. When our nurses went in to do the home-based care, they realized that with regular medication some of these people’s lives could be saved. They made an agreement with the local hospital: in exchange for bringing people in to be tested, the hospital doctors would provide medicine—of course the doctors had to do the tests and write the prescriptions—and our nurses would monitor the patients and administer home care.

What ended up happening was that the project had an extremely high rate of people taking the medicine on schedule—much better than rates in the hospital itself. The doctors at the hospital began to realize that within the home-care project, instead of a typical 45 percent rate of taking the medicine on schedule, rates were more like 95 percent. They asked what we were doing differently, and the difference was that we were going into the home and dealing with all the problems the family had—not just the one sick person, but the kids that needed food and education, the family structure, and the behaviors that had led to getting AIDS in the first place. All these issues were being addressed from a Christian perspective—not requiring the people to profess any faith in Christ, because that was not the point; the point was to help the family and communicate to them the love of Christ. And so it didn’t matter whether the families were Muslim or nonreligious, because what we were doing was just working with the families and presenting Christ’s love to them. Eventually this project grew into a cooperation with three hospitals and 13 clinics that were responsible for all the AIDS patients in half the city of Addis Ababa. We have a TB program now, in addition to the AIDS program, and a microenterprise program to try to help the families earn income. Our work spans the needs of the family groups and the community.

Can you talk about the relevance of this kind of broader, family- and community-oriented approach to maternal health?

Blees: Maternal health in particular has to be more comprehensive, because there are so many societal factors and family factors that influence maternal health. For example, you’d mentioned fistula—but the reason that the girls end up with this problem in the first place is because of family practices: excessive labor when they’re too young, delivering children when their bones aren’t fully formed—that kind of thing—but with the proper intervention, we can at least come in and talk about alternatives to the factors that actually lead to this problem. So it really needs something a whole lot bigger than looking at a particular physical problem.

It seems that trust is a key to your work—especially medical care, which may deal with topics that are sensitive or taboo, like HIV/AIDS or childbirth and pregnancy. Can you talk about how you go about building trust in a community?

Caggiano: One of the key factors, of course, is that our people live there—they’re moving to a community long-term, so you have a doctor, say, who comes in with his family. He and his family become an integral part of the community and they purposefully try to integrate themselves Our people go intentionally to become a part of the community and live among the people and develop friendships with them. They meet people in social settings, particularly as part of a church-building effort where a community is created. They meet with the local people in the context of the local environment as well as at the clinic. There’s a bond and a friendship and a trust that enters in because our people are not there just to come in, do a job, and get out. That’s one part of it.

The other thing is preventative medicine. There are reasons why people get sick. We look at these factors, rather than just being stationed at the hospital taking every patient that comes in. By working in the community with the factors that are leading up to illness, we can help them not get sick in the first place. When people see that you’re reaching out to them in that way then they begin to say, “Oh, these people really care about who we are and they’re not just coming in because they think they’re smarter than we are.” If you just go in to “fix” a problem, people will begin to believe that it’s impossible for them to do it on their own, and that builds dependency. But by working with the people and showing them that you care about them by helping them not to get sick in the first place, then they begin to realize, “I can do something; I’m part of this.”

It’s a tremendous thing when that connection is made and people realize it’s just a matter of training or learning. We have a lot of training tools that are visual or oral rather than textual, so they don’t require much literacy in order to help people have a better quality of life. That’s another major factor.

Do you provide cultural and language training?

Caggiano: Yes, missionaries will learn the language before they are deployed to work in an area. They might spend a year or two getting ready to go. For example, if people are going into one of the Francophone countries they might spend a year in France or a year in Quebec to learn French. And then they’ll have a period of orientation, and then become part of the community, so they can have casual conversations with people. This helps build relationships beyond just the medical factors.

Blees: Working in an institutional setting, we also have a unique opportunity that other organizations may lack. When you’re working eight hours a day with the same group of people—for example, among the staff at the hospital—you have the opportunity to really build trust with them. We work from the perspective of treating our national staff not like they’re our employees, but in partnership, with the attitude that we’re all in this together, really investing in trust with every one of them—to build trust and teamwork among themselves as well as with us. It takes time. I spent 10 years in West Africa in our hospital in Liberia and when we began to treat our staff like fellow workers instead of our employees, it changed everything: local staff began to take on ownership of the end result. It was really gratifying to be able to sit in on a meeting and have one of our Liberian staff members stand up and begin to chide his fellow workers about their work habits, because we didn’t have to say anything.

They took so much ownership that they wanted to continue the ministry in subsequent years, even through the war in Liberia in 1990 when we [Westerners] were all kicked out of the country. And it’s still going on today—their leadership has carried it on since 1990. It’s really been gratifying to see how the end result has been, since we invested in training starting in the 1980s.

Just today the hospital director of the Galmi Hospital in Niger, which we’ve been working with since the early 1960s, was here talking about all the Nigerien staff key to the survival of the hospital. There’s a complete investment in them as coworkers and a real dependence on them for the success of the whole hospital. It’s really neat to see, because of course it wasn’t always that way—with the colonial mindset that the Western nations initially brought in. We’ve seen a big change in the last 20 years to bring about a completely different mindset: that we have to get the local people empowered and owning the success of the ministry, and that’s what we’re doing now.

Barnshaw: I think it’s key to work ourselves out of a job—otherwise we become part of the process. Sustainability is a key piece. We bring in not just medical doctors, but also other missionaries and children, which often leads to the creation of new schools. So not only is the work medical, but there’s also education involved. And bringing in more people and families brings in a richer cross-cultural element to the work.

The other piece of our work I want to mention is our focus on orality. About a third of the world’s population is illiterate, and many of them are the people in the greatest need. Even for those who can read, their parents and grandparents often can’t, so when they communicate with them they do so orally. We’ve developed oral and visual tools to teach about HIV/AIDS and malaria. Malaria affects tremendous numbers of children under 5 years of age, and pregnant mothers are more susceptible to it. And it’s often compounded by HIV/AIDS as well.

You mentioned the importance of building accountability among locals. Are there other ways that SIM measures effectiveness? Do you have indicators other than just numbers that you use to gauge your impact?

Caggiano: This goes to something that’s strongly distinctive about our work: we’re not driven by those numbers. Our people go because they want to share the love of Christ with people, have relationships with them, and see them grow personally as well as physically. So we focus on that and oh, by the way, there were this many surgeries done. We’re not actually requiring the doctor to report back to us how many surgeries he’s had—and in fact it is very difficult to get that information. As the database person, I’m in contact with people in the field, trying to keep track of a lot of different statistics of even just where people are and what are they doing, but we are not actually requiring them to report back to us with those kinds of numbers. We do get that information and we like to have it, but that’s not the driving factor. Instead we ask, have you made an impact in the community, is the community growing, are there more people involved, how many relationships have you built.

The doctor from Galmi Hospital who was here speaking this morning wasn’t talking about how many beds they have in the hospital, he was talking about how they were able to build into the lives of the people there. That’s what we want to hear about, that’s what we talk about, and that’s what drives us—not so much how many fistula operations were done this year. We ask if we are impacting the community in a positive way; are lives being changed for the better; are we allowing them to flourish on their own and not depend on us.

Blees: As an example, in southern Sudan, when the peace treaty came about five years ago [in 2005], many of the two million displaced persons from that area began to flood back into southern Sudan. Our work in the Sudan dates back into the 1920s, but of course with years of prolonged conflict, as millions were being displaced our missionaries had to leave, too. When the Sudanese began to return recently, we went back with a multi-pronged approach to try to assist the returning refugees. First of all we went in with an educational program, a teacher training course to try to teach Sudanese how to teach their own people. Then we went in with the medical community, going village to village with a health care certificate program, to teach the local people how to maintain their own health and establish hospital bases for medical situations that needed referral.

Among the many things we were doing was AIDS education. Many of the Sudanese had come into contact with AIDS when they were displaced, but didn’t really know anything about it, so we came in with an AIDS education program, funded by USAID. It was really successful the first year, but as USAID found that there were more refugees pouring across the border from the south, from Kenya and Uganda, rather than where we were working over on the eastern border in Ethiopia—because that’s where historically our work had been and where the people knew us. USAID took the money from our area and redirected it to the south. Well, we didn’t have any people down there, so we lost that grant. It just shows the difference when your perspective is different and when your reason for being somewhere is different; USAID is driven by numbers, but our work continued to go on without the USAID money. The SIM people that were in there were doing it sacrificially; they weren’t in it for the money at all. The money just made it easier to get around—you could have a car instead of having to walk or take a bicycle, or maybe the quality of your house is a little bit better or maybe you have an office that has windows instead of a hole in the wall—things like that. We still continue to do the work even today. So that shows the difference it makes when you’re not driven by the numbers. You make a commitment to the people and they know that.

Given these vast differences in motivations and approaches, what do you see as the way to move forward? Where is the common ground for partnerships?

Blees: What we’ve found, particularly working with USAID or funding agencies in Australia and Canada, which is where we get most of our government funding, is that working in partnerships in the country itself is the most effective thing to do—not just getting an outside grant. In southern Sudan, for example, we worked with World Vision and with several other organizations, and we partnered together. We’ve found in all the countries where we work that it’s far more effective to find the NGOs and the other Christian organizations that are doing what we’re doing and group together, and then approach USAID or Canada or Australia. Rather than focusing on a narrow geographic area, we try to partner and build a network first, and then approach the funding agencies, and it works much better that way.

Caggiano: We don’t want to be forced to bail because someone turned off the faucet of money.

What do you see as the greatest challenges to your work, especially your medical work, and how do you address them?

Caggiano: Working with a community holistically and transitioning to local people doing for themselves is not always easy because of cultural differences. Westerners have grown up in a world that is systematic and analytical and procedural, and others may have grown up in a culture that is more relational, or in an environment like a refugee camp—where they don’t know what it’s like to make all of their own decisions. So when you try to let them take over things, there’s a tension of how to do that hand-off: how do you train people in a way that makes sense, or what equipment do you bring into a place—can they maintain it on their own, can they get the necessary supplies?

When it comes to medication, if you bring medications into a home but there’s nobody to make sure patients take them, it’s going to be a failure. Even down to an individual basis, there has to be some way that people understand what they need to do to take all the medications, or in an institutional setting, for example, how and when to do the proper maintenance so that generator is there when they need it, and so on. Making that transition is very difficult. Sometimes we’ve done that well and sometimes it didn’t work well.

Blees: It’s difficult because people think differently. In the process of teaching about malaria, one of the things emphasized is to always make sure you take all the medicine that’s given to you. But in a group or a community that is constantly hungry or constantly needy, when they have the opportunity to get food they eat as much as they can because they don’t know when they’re going to eat again. If you give them a bottle of pills and say make sure you take “all of them,” well then, all is better—they might down them all at once. Now you or I know that’s not the right way to do it, but it’s not obvious if you’re working with a different way of thinking.

Another example: when Westerners put their dishes in the cupboard, they put their plates in one stack and their glasses in another. But when Liberians put their dishes in the cupboard, they put a plate and a cup and a spoon, then next to it another plate and another cup and another spoon. It’s not that it’s illogical or wrong—it’s just a different way to think.

One of the biggest issues with maintenance is that we always had to replace doorknobs. None of their doors had knobs—just a handle or a lever. Patients in the hospital would have visiting family members who had never seen a doorknob, and they didn’t know how to turn it. They’d just bang on the knob until it would fall off. So we had to change all the hardware to something they could identify with and understand.

Figuring out how they think is a huge challenge—we don’t always get how they think, even when we think we do. And we believe our way of thinking is the right way. But the reality isn’t a right or a wrong way.

In the hospital in Liberia in the early 1980s we had a local head nurse who was really great. She really knew her stuff. But when her child got sick, she took her to the witch doctor and the baby died. We realized that we’d made a big mistake. We’d taught her the technical stuff—she could follow directions like a cookbook—but there was nothing in the heart. We had never gone to the point of really helping her to understand the principles behind all the things we were teaching.

In the 1980s, after we had taken a different approach, our workmen came back from the country after they’d all gone back to their villages one Christmas. At the next staff meeting one of the guys pointed out that now when they go home, they all get sick because the water isn’t clean—and they had become used to the clean water we had where we were working. They’d learned the principles of why we clean the water and what the impacts of that could be on their families and their children—which goes to the root of the issue of maternal and infant health as well. The key is training in principles and treating local people like fellow workers.

I love the doorknob idea. It’s a great story but also an analogy for all kinds of things.

Barnshaw: The way to open a door to a healthy future, if you like.

Caggiano: If you don’t think about what someone is really thinking, if you just get mad because they keep breaking the doorknob and don’t take the time to figure out what’s going on, then you’ll never get anywhere. But when you finally figure that out—and it’s not always that obvious—then all of a sudden you’ve made progress.